Professional Skills
Urology Core Module
Trustin Domes
Outline
• Brief Anatomy of Scrotum and Prostate
• Physical Examination: CVA, Scrotum and DRE
• Case Scenarios
– LUTS
– Hematuria
– Upper and lower urinary tract obstruction
– Scrotal Masses/Pain
Anatomy of Scrotal Contents
• Vessels:
– Testicle has 3 arterial blood
supplies:
• Testicular artery
• Cremasteric artery
• Deferential artery
– Pampiniform venous plexus
•
•
•
•
Lymphatics
Nerves
Cremasteric muscle/fascia
Vas deferens
Anatomy of Scrotal Contents
• Vas is the most
posterior
component of
spermatic cord
• Tunica vaginalis
surrounds the
anterior 2/3rd of the
testicle and creates
a potential space
for hydroceles and
hematoceles
Clinical Anatomy of the Prostate
Verma S , Rajesh A AJR 2011;196:S1-S10
Prostate Anatomy
• Peripheral Zone = 85% of prostate cancer
originate in this zone, therefore are detected
on DRE
• Transition Zone = site of benign prostatic
hyperplasia
CVA and Ballottement
If CVA tenderness think:
- Renal colic
- Pyelonephritis
- Significant renal trauma
- Renal vascular occlusion
If you can ballot the kidney think:
- Large renal mass
- Polycystic kidney disease
- Severely hydronephrotic kidney
Physical Examination of the Scrotum
• Best to examine the man in both the supine
and upright positions
– Helps to demonstrate conditions that change with
position: hernias and varicoceles
• Bimanual examination of each testicle, adenxa
and spermatic cord
– Testicular size, consistency, masses, tenderness
• Normal testis size 16-20 cc (2 x 4 cm)
– Examine cord upright (+/- valsalva) to assess for
presence of vas deferens, inguinal hernia and
varicocele
Cremasteric Reflex
• Reflex elicited by stroking the medial thigh
causes an ipsilateral contraction of the
cremasteric muscle (bringing the testicle
closer to the external inguinal ring)
• Reflex tests L1-L2 (genitofemoral nerve
responsible for afferent and efferent limbs)
• Typically absent in testicular torsion
– Negative predictive value of over 90%
Transillumination
• Important to help
differentiate solid
from fluid-filled
masses
• Hydroceles and
spermatoceles will
transilluminate,
other scrotal
masses typically
WILL NOT
Hydrocele
Varicoceles
• Dilated veins of the paminiform plexus
• Predominant left-sided (98%)
• Isolated right-sided varicocele may be
caused by a retroperitoneal
– NEED abdominal imaging
• Varicocele grading:
– Grade I: palpable only with valsalva
– Grade II: easily palpable without
valsalva
Grade III: “bag of worms”
– Grade III: large, visible through
scrotal skin
Digital Rectal Examination
Comment on:
• Prostate
• Size
• Symmetry
• Consistency
• Tenderness
• Nodules
• Rectal/Anal Masses
• Rectal Tone
Prostate size
Average prostate size is
approximately 25 cc in men
older than 50 years
25 cc
150 cc
How many finger-breadths
across?
Can you get to the top (base)?